Challenging and uncommon diagnosis of long-evolution ascites

Our plain-English summary of Challenging and uncommon diagnosis of long-evolution ascites, by M. Gravito-Soares, E. Gravito-Soares, J. Almeida, et al (BMJ Case Reports, 2017).

The study

• Authors: M. Gravito-Soares, E. Gravito-Soares, J. Almeida, J. Fraga, L. Tomé
• Journal: BMJ Case Reports
• Published: 2017;2017
• Type of article: Case report
• Read it: PubMed · Publisher · Free full text

Abstract

This is a case report of a 45-year-old Caucasian man with chronic alcoholism. No history of liver disease or asbestos exposure. He complained of ascites during the last 3 years with worsening in the last year with severe ascites development. Diagnostic paracentesis showed SAAG 1.1 and high cellularity with neutrophil count >250 cells/µL. Ascitic fluid cytology revealed reactive mesothelial hyperplasia. Thoracoabdominopelvic ultrasonography/CT/MRI and fludeoxyglucose positron emission tomography/CT showed 'omental cake' pattern suggesting peritoneal carcinomatosis. An exploratory laparoscopy revealed moderate interloop adhesions and necrosis with whitish exudate in the right pelvic excavation. Biochemical/cytological/histological/microbiological study only revealed reactive mesothelial cells, necrosis and lymphohistiocytic inflammatory infiltrate. A second exploratory laparoscopy with liver and peritoneal biopsies and appendectomy/mesoappendix excision showed a well-differentiated tubulopapillary mesothelioma. The patient was referred for intraperitoneal chemotherapy and is undergoing monthly therapeutic paracentesis.

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In plain English

This case report described a 45-year-old Caucasian man with chronic alcoholism who had worked as a garbage collector, with no history of liver disease or previous exposure to asbestos. Mild ascites (fluid in the abdomen) studied three years earlier had no conclusive diagnosis, and in the last year it became severe. Fluid cytology showed reactive mesothelial hyperplasia negative for malignancy. Decompensated cirrhosis with spontaneous bacterial peritonitis was considered at first and treated with an antibiotic and albumin, which the authors call an initial misdiagnosis. A CT scan suggested peritoneal carcinomatosis. A first exploratory laparoscopy found small nodules across the peritoneum, but the biopsies were inconclusive. After the ascites became refractory, a second laparoscopy with biopsies led to a diagnosis of well-differentiated papillary mesothelioma of the peritoneum (WDPMP), a rare subtype. The tumour was considered too extensive for complete surgical removal, so intraperitoneal chemotherapy was proposed. The authors also reviewed five previously described male cases, none with a history of asbestos exposure. The authors concluded that distinguishing WDPMP from reactive mesothelial hyperplasia is very difficult and that diagnostic laparoscopy is crucial for the definitive diagnosis.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report of one patient, with a brief review of previously published cases of WDPMP in men
• Who was studied: One 45-year-old Caucasian man with chronic alcoholism who had worked as a garbage collector for several years
• Exposure: No asbestos exposure was reported. The patient had chronic alcoholism (120 g/day) and had worked as a garbage collector.
• Main results:
  • Three years before, the patient had been extensively tested for mild ascites with no conclusive diagnosis.
  • Diagnostic paracentesis showed high cellularity (3900 cells) with a high neutrophil count (1800 cells/µL). Ascitic fluid cytology showed reactive mesothelial hyperplasia negative for malignancy.
  • Decompensated cirrhosis with spontaneous bacterial peritonitis was initially considered, and cefotaxime and human albumin were started. The authors describe this as an initial misdiagnosis.
  • CT showed massive peritoneal fluid and an 'omental cake' pattern suggesting peritoneal carcinomatosis of unknown primary tumour.
  • The first exploratory laparoscopy found multiple 5 to 10 mm nodules throughout the parietal peritoneum. Biopsy and fluid studies were inconclusive.
  • The patient later developed refractory ascites requiring monthly therapeutic paracentesis.
  • After a second laparoscopy with liver and peritoneal biopsies and appendectomy, WDPMP was diagnosed.
  • Intraperitoneal chemotherapy was proposed because the tumour was too extensive for complete surgical excision.
  • In the authors' review, five WDPMP cases had previously been described in men, aged 36 to 70 years, with no history of asbestos exposure in any of them.
• The authors' conclusion: The authors concluded that distinguishing WDPMP from reactive mesothelial hyperplasia is very difficult, and that diagnostic laparoscopy is crucial for the definitive diagnosis.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Peritoneal mesothelioma.

Medical terms in this study, explained in our Lexicon: Ascites, Asbestos Exposure, paracentesis, Ascitic Fluid Cytology, Reactive Mesothelial Hyperplasia, Necrosis, Exudate, Reactive Mesothelial Cells.

Related studies

• An unusual case of ascites: pitfalls in diagnosis of malignant peritoneal mesothelioma — J.R. Clark, W.B. Ross (2000)
• Metastatic peritoneal mesothelioma in the setting of recurrent ascites: a case report — V. Samedi, S. White, et al. (2010)
• "Signet-ring" cells--a caveat in the diagnosis of a diffuse peritoneal mesothelioma occurring in a lady presenting with recurrent ascites: an unusual case report — B. Rekhi, S. Pathuthara, et al. (2010)
• A Rare Case of Biphasic Malignant Peritoneal Mesothelioma with Refractory Ascites — T. Komaki, H. Urata, et al. (2017)
• The role of peritoneal biopsy in the diagnosis of ascites — P.F. Jenkins, M.J. Ward (1980)
• A Single-Center Experience: The Diagnostic Role of Peritoneoscopy in Patients with Exudative Ascites — B. Abaylı, G. Gençdal (2019)

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